Long term care facilities and residents' doctors should
consider combining medication treatment with psychological and
behavioral approaches, such as strength-embedded psychotherapy,
for a range of psychological disorders.
Currently, psychiatrists and primary care providers in long term care are prescribing
drugs and more drugs as the only treatment for psychological
disorders. But the addition of Strength-Embedded Psychotherapy
(SEP) is a targeted way to change behavior in the direction of
strengths and improve results for residents.
If a resident develops a frozen shoulder or blows out a knee, the orthopedist
would refer him/her to physical therapy, prescribe an NSAID,
and, if needed, consider surgery. In mental health, we owe our
patients nothing less than the same multimodal approach. Adding
psychotherapy to a drug regimen, in this sense, is the mental
health equivalent of taking of a multi-modal approach to
In long term care and elsewhere physicians are
comfortable writing prescriptions because they believe drugs
will affect the functioning of the brain, thereby, improving
symptoms. But so does psychotherapy. In fact, preliminary
evidence suggests that some types of psychotherapy work, in
part, by changing the physiological dynamics of the disorder. In
so doing, psychotherapy, when combined with medication therapy,
offers residents the best chance of returning to more normal
For example, in long term care, a psychiatrist
might choose to use a combination drug/psychotherapy approach
for a resident with obsessive-compulsive disorder (OCD).
S/he might start the resident on a serotonin reuptake inhibitor,
while, simultaneously referring the resident to the house
psychologist for strength-embedded psychotherapy. If the patient
responds early and well to the psychotherapy, the physician may
not have to increase the medication, thereby limiting the side
effect possibilities. But if the patient does not respond
quickly to the psychotherapy or has multiple co-morbid
conditions not targeted by it, the physician could then consider
increasing the dosage of the drug. This type of combination is a
treatment protocol that is comparable to the default model used
in the rest of medicine. The problem is that psychiatric
professionals in long term care and elsewhere simply neglect
One factor is the structure of our mental health system.
Insurers don't often offer payment for integrated care that
includes combined-treatment approaches and alliances with other
providers that are evidence-based.
Also, our society tends to be
pill-happy. The pharmaceutical industry contributes to that by
aggressively promoting its products through direct-to-consumer
advertising that creates the impression that their products will
bring quick results. Unfortunately, there is no pharmaceutical
industry equivalent that promotes psychological and behavioral
approaches. And the healthcare industry has yet to embrace
disease management models in the treatment of psychiatric
disorders that include evidence-based psychosocial
As a result, residents are mainly prescribed only
drugs or several drugs in combination to treat psychiatric
disturbances. Such interventions are helpful, but they could be
more effective and less risky if psychotherapy were part of the
central treatment mix. Psychiatric treatment in long term care
and elsewhere is comparable to treating diabetes without
addressing diet and exercise or treating an injured joint
without prescribing physical therapy.
Similar to the treatment
of other chronic illnesses, combining psychotherapy and
pharmacotherapy would usually require collaborative treatment
between psychologist and psychiatrist or attending
physician. Combined treatment is beginning to show better and
better results in research studies. In several areas combined
therapy is found to produce better results than either treatment
As more results like these continue to emerge, it will
become hard for professionals in long term care to ignore.
However, there is enough data now to warrant moving this enlightened
We need to demand that the better treatments
be made available to our residents in long term care. As long
term care professionals continue to hear about the promising
results generated by psychotherapy, they will start demanding
that this type of treatment be made widely available to their
residents. This will likely require further utilization of the
house psychologist to implement and design the psychological
It's time that we as health care and long term
care professionals figure out ways to offer strength-embedded
psychotherapy to residents who could benefit from this type of
targeted behavioral approach.
Dr. Michael Shery is the founder of Long Term Care Specialists in
Psychology, a mental health firm specializing in consulting to the
long term care industry. Its website, WWW.NursingHomes.MD ,
provides state-of-the-art mental health treatment, facility staffing and career
information to long term care professionals. To get a copy of
the special report, "How to Reduce Residents' Depression with
Strength-Embedded Counseling," click firstname.lastname@example.org.
Put "Special Report" in the subject field.
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